Twenty hospital consultants, working in a range of non-HIV
specialisms, took part. Twelve worked in Brighton or another high-prevalence
area, all in the south east of England. GPs were also approached, but proved to
be impossible to engage in the research.
Almost all acknowledged that their knowledge of HIV was
outdated and had not been updated since early in their career. The little time
that was available for training was focused on their own specialist area of
Stigma and stereotyping had an impact on the decision to
offer a person an HIV test. “Clinicians tended to hold in their mind an idea of
the kind of person who might be at risk of HIV,” Youssef said.
This usually included gay men and
injecting drug users, but older people were generally seen as being less at risk.
Older people might be imagined as being asexual or just ‘more sensible’, she
said. Older people who did have HIV were assumed to have acquired it – and had
it diagnosed – several years before.
The clinicians interviewed were not necessarily working in
departments where routine HIV testing would be recommended (even in a high
prevalence area), but could be expected to offer an HIV test when a patient had
a symptom or condition that could potentially be linked to HIV (an indicator
However, they tended only to consider HIV in ‘unusual’
cases, for example when people did not respond to treatment or had recurrent
symptoms. Younger patients were more likely to be perceived as having an unusual
case, whereas older people were expected to be unwell or to have co-morbidities
that would complicate their treatment.
Youssef said that clinicians usually started with the most likely
causes of a symptom, focusing on those within the realms of their own
speciality. Even when they were aware of the list of indicator conditions in
HIV testing guidelines, many felt that some of these were far too common in
older people to warrant testing for HIV. One endocrinologist in a low
prevalence area said:
tricky, thinking about it, all of my patients have got dementia, so which ones
am I gonna screen then?”
They were also uncomfortable discussing HIV testing,
especially with older patients. Many felt that their patients would be offended
and feel judged if an HIV test were offered. According to a cardiologist in a low
“Most of them tend to
look completely appalled, and think that you’re accusing them of being a drug
addict or a sex maniac or something like that.”
Discussing HIV testing was seen to be more challenging if it
was not perceived to be directly relevant to the appointment or if the
clinician was much younger than the patient.
During interviews, the clinicians made a number of
suggestions that could encourage them to test more appropriately, including:
- Education about how to discuss HIV testing with patients
- Up-to-date information on consent procedures
- A flow diagram of the testing process, showing who would
deliver a positive result and how the patient would be linked into care
- Shorter lists of indicator conditions, tailored to their
area of medicine.